Leukemia, Acute
Leukemia, Acute
| DRG Category: | 835 |
| Mean LOS: | 8.3 days |
| Description: | MEDICAL: Acute Leukemia Without Major OR Procedure With CC |
Leukemias account for approximately 8% of all human cancers, and approximately half of these cases are classified as acute leukemia. Acute leukemia, a malignant disease of the blood-forming organs, results when white blood cell (WBC) precursors proliferate in the bone marrow and lymphatic tissues. The cells eventually spread to the peripheral blood and all body tissues. Leukemia is considered acute when it has a rapid onset and progression and when, if left untreated, it leads to 100% mortality within days or months.
There are two major forms of acute leukemia: lymphocytic leukemia and nonlymphocytic leukemia. Lymphocytic leukemia involves the lymphocytes (cells derived from the stem cells and that circulate among the blood, lymph nodes, and lymphatic organs) and lymphoid organs; nonlymphocytic leukemia involves hematopoietic stem cells that differentiate into monocytes, granulocytes, red blood cells (RBCs), and platelets. Up to 90% of acute leukemias are a form of lymphocytic leukemia, acute lymphoblastic leukemia (ALL), which is characterized by the abnormal growth of lymphocyte precursors called lymphoblasts. Acute myelogenous leukemia (AML) (also known as acute nonlymphocytic leukemia, or ANLL) causes the rapid accumulation of megakaryocytes (precursors to platelets), monocytes, granulocytes, and RBCs. As the disease progresses, the patient may have central nervous system (CNS) dysfunction with seizures, decreased mental status, or coma and renal insufficiency. Death occurs when the abnormal cells encroach on vital tissues and cause complications and organ dysfunction.
Approximately 45,000 new cases of leukemia occur each year. AML is the most common adult leukemia, and two out of three children who develop acute leukemia develop ALL. Approximately 22,000 adults and children die of all forms of leukemia each year. Patients with AML or ALL can be kept in long-term remission or cured in approximately 20% to 30% of adults. Five-year survival rates for children with ALL are close to 80% and for children with AML are close to 40%.
Causes
The exact cause of acute leukemia is unknown, but there are several risk factors. Overexposure to radiation even years before the development of the disease, particularly if the exposure is prolonged, is a major risk factor. Other risk factors include exposure to certain chemicals (benzene), medications (alkylating agents used to treat other cancers in particular), and viruses. Other related factors in children include genetic abnormalities such as Down syndrome, albinism, and congenital immunodeficiency syndrome. People who have been treated with chemotherapeutic agents for other forms of cancer have an increased risk for developing AML. Such cases generally develop within 9 years of chemotherapy.
Genetic considerations
Several genetic disorders increase the risk of leukemia. Persons with Down syndrome have a lifetime leukemia risk that is 15 times greater than that of the general population. The heritable disorders Fanconi’s anemia, Bloom’s syndrome, and ataxia telangiectasia also increase the likelihood of leukemia. AML can be caused by mutations in CEBPA and NMP1. Familial platelet disorder also predisposes individuals to AML through autosomal dominant mutations in RUNX1.
Gender, ethnic/racial, and life span considerations
ALL is the most common type of childhood leukemia; the majority of patients are under age 10, with the peak age for children to develop ALL between ages 2 and 3. In children, AML is most common in the first 2 years of life and less so in later years. AML tends to increase in occurrence in the teen years but most often strikes older people; the average age of a patient with AML is 65. Males are more susceptible to AML than females, and the disease is more common in European Americans than in other Americans; more than twice as many European Americans as African Americans develop ALL.
Global health considerations
The global incidence of leukemia is approximately 6 per 100,000 males per year and 4 per 100,000 females per year. The incidence of diagnosed acute leukemia is three times higher in developed than in developing countries.
Assessment
History
Question the patient (or the parents of the patient, as appropriate) about any exposure to radiation, chemicals, viruses, and medications, including chemotherapy for cancer. Determine the adult patient’s occupation and pay particular attention to radiation exposure of healthcare workers, workers in a power plant, or those serving in the military. Often, the patient describes a sudden onset of high fever and signs of abnormal bleeding (increased bruising, bleeding after minor trauma, nosebleeds, bleeding gums, petechiae, and prolonged menses). Some patients report increased fatigue and malaise, weight loss, palpitations, night sweats, and chills. Parents of children with leukemia often report a series of recurrent pulmonary, urinary tract, and perirectal infections. Patients may also complain of abdominal or bone pain.
Physical examination
The patient appears acutely ill, short of breath, and pale. Children are often febrile. When you inspect the lips and mouth, you may note bleeding gums and ulcerated areas of the mouth and throat. On palpation, you may feel lymph node swelling and enlargement of the liver and spleen. When you auscultate the patient’s lungs, you may hear decreased breath sounds, shallow and rapid respirations, a rapid heart rate, and a systolic ejection murmur.
Psychosocial
When the diagnosis of acute leukemia is made, patients, parents, and significant others are shocked and fearful. If the patient is a child, determine the patient’s stage of development and his or her relationship with parents, caregivers, or grandparents. If the patient is an adult, determine the patient’s job, childcare, and financial responsibilities. Assess the patient’s home situation to determine the possibility of home healthcare. Determine the support systems available to the patient, including emotional, religious, financial, and social support.
Diagnostic highlights
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Complete blood count and differential | RBCs 4–5.5 million/μL; WBCs 4,500–11,000/μL; hemoglobin 12–18 g/dL; hematocrit 37%–54%; reticulocyte count 0.5%–2.5% of total RBCs; platelets 150,000–400,000/μL | Increased WBC counts (notably blast cells), lowered RBC count, insufficient platelets | Changes in numbers of different blood cell types and how the cells look under a microscope can suggest leukemia; overproduction of WBCs halts production of RBCs and platelets |
| Bone marrow aspiration/bone marrow biopsy | No leukemia cells present | Leukemia cells present; 30% blast cells required for diagnosis of acute leukemia; < 5% blast cells for diagnosis of remission | A thin needle is used to draw a small amount of liquid bone marrow; a small cylinder of bone and marrow (about 1/2–in long) is removed with a slightly larger needle; the site of both samples is usually at the back of the hipbone |
Other Tests: Other supporting tests include x-rays, lymph node biopsy, computed tomography scan, magnetic resonance imaging, ultrasound, cytochemistry, flow cytometry, immunocytochemistry, and lumbar puncture.
Primary nursing diagnosis
Diagnosis
Risk for infection related to decreased primary and secondary responsesOutcomes
Immune status; Knowledge: Infection control; Risk control; Risk detection; Nutrition status; Treatment behavior: Illness or injury; Hydration; Knowledge: Infection controlInterventions
Infection control; Infection protection; Surveillance; Fluid/electrolyte management; Medication management; Temperature regulationPlanning and implementation
Collaborative
The treatment for acute leukemia occurs in four phases: induction, consolidation, continuation, and treatment of (CNS) leukemia. During the induction phase, the patient receives an intense course of chemotherapy that is meant to cause a complete remission of the disease. Complete remission occurs when the patient has less than 5% of the bone marrow cells as blast cells and the peripheral blood counts are normal. Once remission has been sustained for 1 month, the patient enters the consolidation phase, during which she or he receives a modified course of chemotherapy to eradicate any remaining disease. The continuation, or maintenance, phase may continue for more than a year, during which time the patient receives small doses of chemotherapy every 3 to 4 weeks. Treatment of CNS leukemia is an essential component of therapy that has replaced irradiation, which leads to significant CNS complications with intensive intrathecal and systemic chemotherapy for most patients.
Some patients also need transfusions with blood component therapy to control infection and prevent bleeding and anemia. Bone marrow transplantation (BMT) is an option for some patients. Early BMTs were allogenic transplants using stem cells that had been harvested from bone marrow from siblings or matched from other relatives or people listed in a donor registry. In autologous BMTs in the 1980s, physicians began using frozen cells harvested from the donor’s own marrow during remission. More recently, a newer form has occurred with peripheral blood stem cell transplant (SCT) or peripheral blood progenitor cell transplant. Multiple pheresis, or removal of cells from the blood, provides the stem cells from the patient for transplantation. SCT permits the use of doses of chemotherapy and radiation therapy high enough to destroy the patient’s bone marrow; after the treatment is completed, SCT restores blood-producing bone marrow stem cells. Radiation treatment is sometimes used to treat leukemic cells in the brain, spinal cord, or testicles.
Pharmacologic highlights
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Chemotherapeutic agents | Varies with drug; treatment for AML generally uses higher doses over a shorter period of time, whereas treatment for ALL uses lower doses over a longer period of time; treatment varies for children and adults and with phases of treatment |
| Decrease replication of leukemia cells and kill them |
Other Drugs: Supportive care and management of complications from chemotherapy are handled with blood products and pharmacologically with antibiotics, antifungals, and antiviral drugs. Growth factors (colony-stimulating factors) may be given to elevate blood counts.
Independent
Focus on providing comfort and support, managing complications, and providing patient education. Determine how the patient is coping with the disease and where you can best provide support. For some patients, improving their comfort is the highest priority, either physically, such as with a bed bath or back rub, or emotionally, such as by listening to fears and concerns and providing interesting distractions. Teach the patient stress- and pain-reduction techniques. Provide mouth care to lessen the discomfort from oral lesions. Support the patient’s efforts to maintain grooming and a positive body image. If the patient is a child, provide age-appropriate diversions, and work with the parents or caregivers to keep the significant others present and involved in the child’s care.
Protect the patient from injury and infection. To limit the risk of bleeding, hold firm pressure on all puncture wounds for at least 10 minutes or until they stop oozing. Limit the use of intramuscular injections and intravenous catheter placement when the patient is pancytopenic. Avoid taking rectal temperatures, using rectal suppositories, or performing a rectal examination. If the patient does not respond to treatment, be honest about the patient’s prognosis. Determine from parents how much information they want to share with the child about a terminal disease. Work with the patient, significant others, and chaplain to help the patient plan for a terminal illness and achieve a compassionate death.
Evidence-Based Practice and Health Policy
Zimmermann, C., Yuen, D., Mischitelle, A., Minden, M.D., Brandwein, J.M., Schimmer, A., …Rodin, G. (2013). Symptom burden and supportive care in patients with acute leukemia. Leukemia Research, 37(7), 731–736.
- Investigators suggest that greater attention should be paid to coordinating supportive services for adult cancer patients. For example, an observational study among 249 adult patients with acute leukemia revealed minimal referrals to supportive care.
- In this sample, 91% of patients reported more than five concurrent physical and psychological symptoms, and 61% reported more than 10 concurrent symptoms. However, only 2% of patients were referred to palliative care, and 14% were referred to psychiatry or psychology services within 6 months of the assessment.
- The most prevalent physical symptoms in this sample were lack of energy (79%), drowsiness (56%), dry mouth (54%), weight loss (54%), and pain (49%). The most prevalent psychological symptoms were difficulty sleeping (55%), worrying (43%), difficulty concentrating (39%), and feeling sad (36%).
- Of the 35 patients who died within the 6-month follow-up period, 6% were referred to palliative care, with a mean time of referral occurring 6 days prior to death.
Documentation guidelines
- Physical response: Vital signs, physical assessment, signs of infection, signs of bleeding, ability to tolerate activity
- Response to chemotherapy or radiation treatments
- Emotional response to the diagnosis of cancer or the use of reverse isolation
- Comprehension of treatment plan, including care: Purpose and potential side effects of radiation and chemotherapy; bone marrow transplant
- Presence of complications: Infection, bleeding, poor wound healing, ineffective coping by the patient or significant others
Discharge and home healthcare guidelines
Teach the patient and significant others about the course of the disease, the treatment options, and how to recognize complications. Explain that the patient or parents need to notify the physician if any of the following occur: fever, chills, cough, sore throat, increased bleeding or bruising, or new onset of bone or abdominal pain. Discuss the patient’s home environment to limit the risk of exposure to infections. Encourage the patient to avoid close contact with family pets because dogs, cats, and birds carry infections. Animal licks, bites, and scratches are sources of infection. The patient should not clean birdcages, litter boxes, or fish tanks. Additional sources of bacteria in the home include water in humidifiers, standing water in flower vases, and water in fish tanks. Encourage the patient to have air filters in furnaces and air conditioners changed weekly. Explain that raw fruits, vegetables, and uncooked meat carry bacteria and should be avoided. If the patient becomes injured, encourage the patient or significant others to apply pressure, use ice, and report excessive bleeding. Teach the patient to avoid blowing or picking the nose or straining at bowel movements to limit the risk of bleeding.
Explain the proper administration and potential side effects of any medications. Teach the patient how to manage pain with the prescribed analgesics and other side effects specific to each chemotherapeutic agent. Explain that the chemotherapy may cause weight loss, even anorexia. Encourage the patient to eat a diet high in calories and protein and to drink at least 2,000 mL of fluids per day. If the chemotherapy leads to anorexia, encourage the patient to eat frequent, small meals several times a day. Arrange for a dietary consultation if needed before discharge. If the patient has oral lesions, teach the patient to use a soft toothbrush or cloth and to avoid hot, spicy foods and commercial mouthwashes, which can irritate mouth ulcers. Encourage the patient to take frequent rest periods during the day and to space activities with rest.
Urge the patient to maintain a realistic but positive attitude. The return to an independent lifestyle is possible with the efforts of a competent healthcare team and the patient’s cooperation. Provide a list of referral agencies as appropriate, such as the American Cancer Society, hospice, and support groups.